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I APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA i Telephone {209} 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address CiC/TCk 6;776- City 7 V C�J. Lot Size /Z C- PM Owner's Name ' ' 'M 10 Address 7 1,J Phone�� Contf actor G�Z� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. . PROP. LINE FOUNDATION-. AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE dF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing S ❑ Domestic/Private ❑ Gravel Pack. ❑ Tracy Type of Casing Specifications ;i ❑ Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout—.— I rout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by - n Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 f 4w I`F�14%- - , -4 1 Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Ll DESTRUCTION I I INo septic system permitted if public sewer is �f available within 200 feet.( (7 Installation will serve: Residence n Commercial — Other Number of living units: Number of bedr*xqns Z Character of soil to a depth of 3 feet: ► Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 6/ d _. Compartments 1.%. PKG. TREATMENT PLT.-.C3 / �' Method of Dispos I 1 �«.-�« .�: � � Distance to nearest: Well +� Foundation Property Line 's LEACHING LINE <04 { ' No. & Length of lines - �' h' Total length/size y� I FILTER BED Cl Distance to nearest: Well Foundation�.__. Property Line SEEPAGE PITS ; H Depth Size _f Number SUMPS ❑ Distance to nearest: Well 'Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance�with.San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District:: # l Home owner or licensed agent's signature certifies the following:-4'l-certify-that-4t4h4-performance of the:work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature i certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant c. for all required cti a drawing'on're a side. Signed ' Title: __ — Date: FCR DEPARTMENT USE ONLY - Application Accepted by Date S Area a!3 Pit or Grout inspection by Date Final Inspection by Dates�� Additional Comments: ''e ❑ Stk 466-6781 ❑ Lodi 369-3621 t3 Manteca 823-7104 ❑ Tracy 835-63385 Applicant - Raturn all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Box 2009,'Stk.,--CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT NO. INFO ♦.EH 13-24{REV.i�a 81 .. . 470 EH 1426